Clinical Documentation Improvement Specialist Resume
Headline : International Physician with years of experience in the Health Industry. Background in General Practitioner, Bio ethicist, Professor and Clinical Documentation Improvement.
Skills : Electronic Medical Record, Clintegrity 360, CDR2.
Description :
- Identified all procedures and secondary diagnoses for comorbidities/complications and documents.
- Identified documentation issues such as quality, appropriateness, completeness, and reimbursement issues and communicate these issues.
- Queried the medical staff and other providers as necessary via written/verbal communication.
- Ensured the timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record.
- Educated physicians, clinicians, and other CDIS staff and coders regarding the necessity of providing complete and clear documentation.
- Assessed the skill level and competency of CDI staff by reviewing Working DRG versus final billed DRG.
- Identified query opportunities missed by CDI staff, to obtain accurate and complete physician documentation.
Experience
5-7 Years
Level
Executive
Education
Certification
Clinical Documentation Improvement Specialist II Resume
Headline : A certified Clinical Documentation Improvement Specialist (CDIS) with over three years of active acute-care in-patients experience, a Physician with over eight years of clinical practice, an ICD-10 trained.
Skills : Technical Skills, Fluent in English.
Description :
- Prepared & coordinated CDS led Bi-weekly meetings for ICD-10 Physician Education.
- Able to discern the value of collecting marginal data against the potential administrative burden of obtaining additional specificity.
- Initiated clinically relevant queries to physicians when documentation requires further specificity to accurately reflect the patients.
- Worked knowledge of 3M 360 Encoder, ICD-10 & Third-Party Payers respective reimbursement systems.
- Conducted follow-up reviews to support & assign a working or final DRG to be assigned upon patient discharge.
- Worked as part of a team that had a projected income revenue goal. Working together we were able to double that goal, with a quarterly earning of dollars.
- Reviewed medical records, identify missing or unclear information, and then act as a point of contact with the Physician to fulfill the record deficit.
Experience
5-7 Years
Level
Executive
Education
Master Of Science
Clinical Documentation Improvement Specialist/Executive Resume
Headline : Currently working as a traveling Clinical Documentation Improvement Specialist. Proficient experience working in multiple EHR, Coding & Reimbursement systems to include Epic, Meditech, 3M360 Encompass.
Skills : Medical Software Systems, Hard Working.
Description :
- Accountable for improved the overall quality and completeness of clinical documentation at each facility.
- Facilitated and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness.
- Exhibited expert knowledge of clinical documentation requirements, DRG assignment, and clinical diagnoses & procedures.
- Created and provided education for members of the patient care team regarding documentation guidelines.
- Completed the initial review of patient records within 24-48 hours of admission.
- Evaluated documentation to assign the principal diagnoses, pertinent secondary diagnoses, and procedures for accurate DRG assignment.
- Information is incomplete or missed then provides appropriate communication with assigned providers.
Experience
5-7 Years
Level
Executive
Education
Nursing
Clinical Documentation Improvement Specialist I Resume
Objective : Registered Nurse with over fifteen years of experience in clinical / critical care nursing, as well as utilization management, case management and clinical documentation improvement.
Skills : Critical thinker, Excellent interpersonal, Team player.
Description :
- Responsible for detailed clinical review of patient records including coding principal diagnosis, comorbid conditions, and procedures.
- Ensured the quality and completeness of clinical documentation through physician queries.
- Facilitated complete, accurate, and specific documentation of diagnosis and level of services provided which is utilized for appropriate coding.
- Utilized software to collect, track, and report outcomes.
- Participated in the analysis and trending of statistical data to identify opportunities for improvement.
- Assisted with the preparation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
- Educated physicians and other members of the patient care team regarding specific documentation needs, reporting, and reimbursement issues.
Experience
2-5 Years
Level
Junior
Education
Nursing
Clinical Documentation Improvement Specialist/Analyst Resume
Headline : Process of transitioning from current residence in Connecticut to new home in Upstate. Seeking to obtain a Nursing position in that geographic region, which builds on and /or broadens.
Skills : OR Circulator, Scrubbing; Med-Surg Nursing.
Description :
- Utilized Nursing knowledge and clinical experience, reviewed patient medical records for accuracy and specificity of clinical documentation.
- Accessed and reviewed patient information via electronic data management systems for additional pertinent information.
- Communicated with physicians via a query process to improve the quality of documentation within the patient record.
- Maintained a computerized data form to track workflow and outcomes.
- Worked together with clinical coding staff to ensure the most accurate reporting/billing of patient accounts.
- Gathered data for quality improvement in the Clinical Documentation Specialist, CDI process.
- Identified variances from practice and policy and participate in the education of physician staff.
Experience
5-7 Years
Level
Executive
Education
Nursing
Clinical Documentation Improvement Specialist/Technician Resume
Headline : To secure a position as a Clinical Documentation Improvement Specialist where will apply skills, knowledge and leadership qualities in providing the most accurate and complete medical records for coding.
Skills : Microsoft Office, Technical Skills.
Description :
- Reviewed medical records concurrently for documentation improvement opportunities.
- Worked closely with physicians and case managers to educate on proper documentation.
- Improved documentation and capture CC and MCC's.
- Improved case mix index and maximize hospital revenue.
- Coded inpatient including heart and back procedures, same-day surgery accounts, ER records, outpatient accounts, skilled nursing facility accounts.
- Award is given for going above and beyond expected duties.
- Increased hospital revenue in six months and improving hospital case mix index.
Experience
5-7 Years
Level
Executive
Education
Business Administration
Clinical Documentation Improvement Specialist/Co-ordinator Resume
Headline : Experience as a Clinical Documentation Improvement Specialist. Areas of expertise include ICU, CCU, Trauma 1, Surgery, Medical. Create and lead in the maintenance of a compliant query process.
Skills : Med-Surg Nursing, MS-Excel.
Description :
- Assigned correct DRG/ICD-9 code and principal diagnosis extracted from clinical data.
- Utilized 3M-HDM software encoder, data input, and to generate monthly reconciliation.
- Created queries to physicians to clarify and specify needed documentation for correct reimbursement from Medicare and Blue Cross/Blue Shield.
- Created letters for first-level appeals to Medicare and Blue Cross/Blue Shield.
- Accessed Paragon EMR software for current clinical data information and HPF software for retrospective patient record information.
- Achieved increased hospital reimbursements above the projected goal.
- Ensured complete and accurate documentation is provided before discharge.
Experience
5-7 Years
Level
Executive
Education
Nursing
Lead Clinical Documentation Improvement Specialist Resume
Summary : A position of responsibility that allows for growth and advancement; utilizing technical, creative, and interpersonal knowledge and skill.
Skills : DRG audits, CDI specialist qualifications, Utilization Review.
Description :
- Presented Review concurrent charts for necessary documentation for coding and DRG assignment.
- Communicated with physicians to obtain additional documentation needed to capture complications and co-morbidities for optimal DRG.
- Developed and implement a plan for both formal and informal education for physicians, nursing, and other clinical staff.
- Identified strategies for changing work process to facilitate complete, accurate clinical documentation.
- Ensured adherence to establish productivity target for record review.
- Created queries for medical records, edit database with replies from physicians.
- Communicated with physicians either verbally or via query form to ensure documentation is clarified or corrected.
Experience
7-10 Years
Level
Management
Education
Management
Asst. Clinical Documentation Improvement Specialist Resume
Objective : Seeking a full time position in the healthcare field where can contribute knowledge and skills as a clinical documentation improvement specialist to successfully help the Organization achieve their goals.
Skills : CPT, HCPCS, ICD-10-CM, ICD-9, D2L Brightspace.
Description :
- Reviewed concurrent inpatient accounts to ensure completeness and accuracy of services provided to the patients.
- Assigned the MS- DRG and look for documentation improvement opportunities.
- Discussed each case with the physician and provide him/her with the tools to improve documentation.
- Looked for query opportunities to improve the SOI/ROM.
- Worked with the coders and auditors to create a new template for the queries which are compliant with ICD-10.
- Improved Health Quality Care through Better Clinical Documentation.
- Built a CDI program in the smaller campus hospital.
Experience
2-5 Years
Level
Junior
Education
MD
Associate Clinical Documentation Improvement Specialist Resume
Headline : Energetic, goal-oriented applicant seeking a new and rewarding full-time career as a coding specialist.
Skills : Bilingual English, Arabic, Hard Working.
Description :
- Reviewed all inpatient records for complete and accurate documentation with regards to ICD-9 coding and MS-DRG specifications.
- Maintained a close relationship with all physicians on staff to ensure adequate and specific documentation.
- Developed coding queries for documentation.
- Audited charts for governmental core measure requirements.
- Utilized ICD-9 diagnosis coding, CPT, and E/M professional fee for the ER and outpatient services.
- Familiar with CMS and commercial insurance requirements for payment.
- Proficient with EMR documentation, 3M Encoder systems.
Experience
5-7 Years
Level
Executive
Education
Documentation
Clinical Documentation Improvement Specialist Resume
Headline : Highly competent Certified Clinical Documentation Improvement Specialist and Foreign Medical Graduate with extensive background in facilitation of physician documentation for patient conditions.
Skills : DRG Audits, CDI Specialist Qualifications, Utilization Review.
Description :
- Inpatient and outpatient pre-surgical level of cared reviews based on CMS and Interqual guidelines.
- Processed appeals for preadmission and presurgical denials.
- Reviewed clinical documentation for consistency and accuracy throughout the stay.
- Created queries and follow up with practitioners.
- Educated practitioners on common queries and answer questions.
- Advised of appropriate ICD-10 codes and CPT codes.
- Assisted and educated the preauthorization team as needed.
Experience
5-7 Years
Level
Executive
Education
Associates
